Grant application 2024 - Regain Sports Charity

Personal details

Your name *

Your age

Your Email Address *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Injury details

Occupation at time of Injury

Your current Occupation

Date of Injury

Level of Injury

Complete or Incomplete

Describe how the injury occurred

Describe ability - and how your injury impairs you

Equipment / Grant request

Applicants can request a maximum of 75% of the costs of the equipment, up to a maximum of £5,000. The Grants Panel can advise of other organisations that applicants can approach, or Regain can provide advice with fundraising activities in the applicants local community

Have you had a Regain grant before and if so how much?

How did you hear about Regain?

Describe the Equipment / Grant Request

Cost of the Equipment / Grant Request

Please describe how you will benefit from the Equipment / Grant request

Have you tried obtaining the Equipment or part funding from any other source?NoYeseg NHS Wheelchair Services, Social Services, Local Health Authority, Motability or other Charity or Trust etc...

If yes - please give details of whom you contacted and whether they were able to assist you or not

Application support

Please provide the contact details of either your consultant, occupational therapist, case manager, physiotherapist, care manager or if appropriate, a relative who we can contact to verify that the equipment requested is suitable

Support Name

Support Email

Support Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Signature of ApplicantI confirm the above is true and accurate

Confirm date of signature

Can you make a contribution towards the cost of this equipment ?NoYes(We do expect ALL applicants to contribute towards the cost)

Have you provided 2 quotes from supplies plus supplier details ?NoYes

Stay up-to-date with what's happeningI would like to receive occasional marketing emails from Regain Sports Charity

Regain is working in partnership with Aspire, who also operate a grants scheme for items such as power assisted add ons and some wheelchairs.I give Regain permission to share my application form with Aspire